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PRACTICAL APPLICATIONS
The Role of Implant Position on Long-Term Success
Chuan-Yi Su,* Jia-Hui Fu,† and Hom-Lay Wang‡
Focused Clinical Question: In the past, im-
plants were placed where the bone was. This mode of
treatment often led to implant-related complications,
such as peri-implant soft-tissue recession, esthetic chal-
lenges, and fractured implants and/or associated supra-
structures. Therefore, advances in soft-tissue and bone
augmentation techniques have enabled implants to be
placed in an ideal three-dimensional position, thus en-
suring adequate peri-implant soft tissue and bone thick-
ness for a stable and successful long-term treatment
outcome. The present report aims to answer the ques-
tion: What are the clinical guidelines for implant place-
ment to achieve long-term success?
Summary: In the maxillary anterior region where
esthetics is of paramount importance, 2 mm of buccal
bone anterior to the implant is preferred. This ensures
stability of the buccal bone plate, minimizing peri-implant
mucosal recession. To achieve an esthetic emergence
profile, the implant platform is generally placed 3 to 4
mm apical to the cemento-enamel junction (CEJ) of the
adjacent teeth and 1.5 to 2 mm away from the adjacent
roots. In the posterior region, a minimum of 1 mm of buc-
cal bone around the implant ensures stability of the buc-
cal plate. Generally, implants with a polished collar are
preferred because the collar can be placed supracrestally
to compensate for any vertical ridge deficiency and yet
not compromise the esthetics of the restoration. The im-
plant is placed 1.5 to 3 mm apical to the CEJ of the adjacent
teeth and 3 to 4 mm away from adjacent roots to create
a smooth transition from implant platform to occlusal plane.
Conclusion: Ideal three-dimensional implant posi-
tioning ensures a long-term stable esthetic and functional
treatment outcome. Clin Adv Periodontics 2014;4:187-193.
Key Words: Bone regeneration; bone substitute;
complications; dental implants; survival rate.
Background
Multiple studies have proved that long-term (‡10 years)
implant survival and success rates are in the high 90th
* Private practice, Kaohsiung, Taiwan.
†
Discipline of Periodontics, Faculty of Dentistry, National University of
Singapore, Singapore.
‡
Department of Periodontics and Oral Medicine, School of Dentistry,
University of Michigan, Ann Arbor, MI.
Submitted September 10, 2012; accepted for publication December 28,
2012
doi: 10.1902/cap.2013.120100
percentile.1-3 Despite the high survival and success rates,
common implant complications include technical compli-
cations (e.g., screw fracture),4 biologic complications
(e.g., loss of peri-implant marginal bone,4 osseointegra-
tion), and esthetic complications (e.g., midfacial mucosal
recession).5 Literature proposed that poor oral hygiene,
history of periodontitis, and cigarette smoking are the
main risk indicators for peri-implant disease.6 However,
the three-dimensional (3D) position of implants in the
dental arch appeared to play an important role, yet not
many studies related the success of dental implants to their
3D position. It has been proposed that implants should be
placed in a prosthetically driven position, so that axial
occlusal forces are exerted on the implant-supported
restoration and fixture, thereby minimizing biomechanical
complications and peri-implant marginal bone loss.7
Buser et al.8 recommended that dental implants in the
esthetic zone (e.g., anterior maxilla) should be placed in
“comfort” zones so that an esthetic implant-supported res-
toration is achieved. The authors proposed that implants
should be placed 1.5 mm away from the adjacent roots,
1 mm apical to the cemento-enamel junction (CEJ) of
the contralateral tooth, and 1 mm palatal to the emergence
of adjacent teeth.8 Bashutski and Wang9 proposed that at
least 2 mm of buccal bone should lie anterior to the implant
fixture. The implant platform should be 1.5 to 3 mm apical
to the CEJ of adjacent teeth, with 1.5 mm between implant
and root or 3 mm between implants.9 The present report
aims to discuss guidelines on implant positioning in the
anterior and posterior regions so that an esthetic and func-
tional implant-supported restoration that is stable over
time can be achieved.
Decision Process
Figure 1 illustrates the guidelines to keep in mind when
placing implants in the anterior and posterior regions.
Bucco-Palatal Position
To minimize hard- and soft-tissue loss over time, the au-
thors of the present study proposed that a minimum of
2 mm of buccal bone thickness should lie buccal to the im-
plant platform in the anterior region (Fig. 2a). To achieve
this, the implant fixture is directed at the cingulum level of
the adjacent teeth. In the posterior region, where esthetics
is not of prime importance, having 1 mm of buccal bone
thickness is acceptable, and the implant fixture is directed
at the central groove of the adjacent posterior teeth. Bone
remodeling of 2 to 2.5 mm will occur at sites undergoing
immediate implant placement.10 As such, it is important
to compensate for this loss of buccal bone thickness. For
Clinical Advances in Periodontics, Vol. 4, No. 3, August 2014 187

P R A C T I C A L A P P L I C A T I O N S
FIGURE 1 Proposed guidelines for implant placement in the anterior and posterior regions.
FIGURE 2 Schematic diagrams of bucco-palatal implant positions. 2a
Bucco-palatal position of an implant placed in a healed site in the maxillary
anterior region. The center of the implant fixture should be directed at the
level of the cingulum of adjacent teeth, leaving a minimum of 2 mm of
buccal bone thickness. 2b Bucco-palatal position of an implant placed in
an extraction site in the maxillary anterior region. The center of the implant
fixture should be directed at the level of the cingulum of adjacent teeth,
leaving a distance of 6 mm from the buccal bone to the center of the
implant, thus compensating for potential buccal bone resorption as the site
heals. (Illustrations courtesy of Mr. Wee-Wah Tok).
188 Clinical Advances in Periodontics, Vol. 4, No. 3, August 2014
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example, the center of a 4-mm-diameter implant should
be 6 mm palatal to the buccal bone flange so that 2 mm
of buccal bone thickness remains after bone remodeling
is completed (Fig. 2b). Conversely, in delayed implant
placement, the center of a 4-mm-diameter implant should
be 4 mm palatal to the buccal bone flange.
Mesio-Distal Position
It was proposed that a safe distance of 1.5 mm between im-
plant and root or 3 mm between implants was needed to
maintain the peri-implant bone.11 Having adequate im-
plant–tooth or interimplant distance maintains the bone
support that preserves the papillary tissues needed for an
esthetic restoration.12 In the anterior region, a single im-
plant has to be centered mesio-distally in the edentulous
space, allowing a distance of 1.5 mm between the implant
and the adjacent roots. For example, if the implant has
a diameter of 4 mm, a minimum mesio-distal ridge width
of 7 mm is needed (Fig. 3a). In the posterior region (e.g.,
restoring a molar), a 5- or 6-mm-diameter implant is com-
monly used. In addition to accommodation for the implant–
root distance, more space is needed for the emergence pro-
file of the restoration. Therefore, a single implant of 5-mm
diameter needs a minimum mesio-distal ridge width of
11 mm, with 3 mm between implant and adjacent root
(Fig. 3b). When placing multiple implants in the posterior
region (e.g., 4- and 5-mm-diameter implants for restoring
premolars and molars, respectively), the clinician has to
consider space distribution between the implants. The cen-
ter of the first 4-mm-diameter implant should be 5 to 6 mm
away from the adjacent tooth CEJ; the center of the
Implant Position and Long-Term Success

FIGURE 3 Schematic diagrams of mesio-distal and apico-coronal implant
positions. 3a Mesio-distal and apico-coronal position of a single implant in
the maxillary anterior region. 3b Mesio-distal and apico-coronal position of
a single implant in the mandibular posterior region. 3c Mesio-distal
positions of consecutive implants in the mandibular posterior region.
(Illustrations courtesy of Mr. Wee-Wah Tok).
Su, Fu, Wang
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P R A C T I C A L A P P L I C A T I O N S
subsequent 4-mm-diameter implant should be 7 to 8 mm
away from the center of the anterior implant. The center
of the subsequent 5-mm-diameter implants should be 7.5
to 8.5 mm away from the center of the anterior implant,
and the final implant should be 9 mm away from the ante-
rior implant (Fig. 3c).
Apico-Coronal Position
In the esthetic zone, it is suggested that the implant plat-
form be placed 3 to 4 mm apical to the adjacent or pro-
posed CEJ so that an esthetic emergence profile can be
fabricated (Fig. 3a). In addition, a bone-level implant is
preferred over an implant with a polished collar to mini-
mize esthetic complications, such as exposure of the pol-
ished collar. In the posterior region, the implant platform
is placed 2 mm apical to the adjacent or proposed CEJ
(Fig. 3b). An implant with a polished collar is preferred be-
cause it makes it easier to maintain oral hygiene. Also, in
sites with vertical bone loss and where esthetics is not
a main concern, placement of the polished collar above
the bone would aid in maintaining the bone height and
crown-to-implant ratio (Fig. 4).
Clinical Scenarios
Case 1
This case presentation illustrates the importance of having
implants placed in the correct 3D position to minimize
postplacement implant complications (Fig. 5).
A 55-year-old Chinese male with a history of chronic
periodontitis and no contributory medical history or drug
allergies, presented at a dental clinic in Kaohsuing, Taiwan,
in June 1991. He was interested in seeking implant therapy
FIGURE 4 Schematic diagram showing the redistribution of crown-
to-implant ratios with change in apico-coronal implant position. An implant
with a polished collar (transparent implant image) could be placed su-
pracrestally, thus giving rise to a more ideal crown-to-implant ratio. Com-
paratively, notice the increase in crown-to-implant ratio when a bone-level
implant (opaque implant image) is used. (Illustration courtesy of Mr. Wee-
Wah Tok).
Clinical Advances in Periodontics, Vol. 4, No. 3, August 2014 189
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P R A C T I C A L A P P L I C A T I O N S

FIGURE 5 Case 1. Presentation of peri-implant bone loss due to incorrect apico-coronal implant position. 5a Baseline radiograph of the edentulous
mandibular posterior right region. 5b Radiograph showing adequate mesio-distal implant positioning from tooth sites #29 through #32. 5c Radiograph of the
installed implant-supported fixed prosthesis replacing teeth #30 through #32. 5d Radiograph showing stable marginal bone levels around the implants in tooth
sites #30 through #32 after 6 months of functional loading. 5e Radiograph of a bone-level implant placed at tooth site #29, 6 months after the tooth was
extracted. The implant at tooth site #29 was placed z2 mm deeper than the implant at tooth site #30. 5f Radiograph showing significant marginal bone loss
around implant in tooth site #30. 5g Radiograph showing significant marginal bone loss around implants in tooth sites #30 and #31, 18 months after the implant
at tooth site #29 was placed. 5h Radiograph of two shorter implants placed at the same apico-coronal level to replace the affected implants at tooth sites #30
and #31. 5i Radiograph showing stable marginal bone level around all four implants after 2 years of functional loading.

for the replacement of missing mandibular right posterior
molars (teeth #30 through #32) (Fig. 5a). Oral informed
consent to be treated was obtained from the patient. Im-
plants with polished collars were placed in the ideal 3D
positions to replace teeth #30 through #32 (Fig. 5b). Sub-
sequently, an implant-supported splinted fixed prosthesis
was installed. At 5 years reevaluation, the bone levels
around implants in tooth sites #30 through #32 were main-
tained at the rough–smooth junction of the implant plat-
form (Fig. 5c). However, tooth #29 had a root fracture
and was extracted (Fig. 5d). Six months after the extrac-
tion, a new implant was placed to replace tooth #29. How-
ever, the implant was placed too deep, thus violating
the proposed guideline that consecutive implants should
be placed at the same apico-coronal level to avoid peri-
implant bone loss (Fig. 5e). Six months after the implant
at tooth site #29 was placed, significant peri-implant bone
loss was observed around tooth site #30 (Fig. 5f). Nonethe-
less, a final crown was placed on the implant in tooth site
#29. Eighteen months later, the patient returned to the
clinic with more peri-implant bone loss at tooth sites #30
and #31 (Fig. 5g). A clinical decision was made to remove
the affected implants at tooth sites #30 and #31 and then
place shorter implants after 6 months of healing to mini-
mize additional vertical ridge resorption as well as inflam-
mation (Fig. 5h). Single cemented implant crowns were
fabricated for tooth sites #29 through #32. A 2-year reeval-
uation radiograph showed stable peri-implant bone levels
around all four implants (Fig. 5i), thereby further support-
ing that implants have to be placed in an ideal 3D position
to minimize implant complications, such as peri-implantitis
or peri-implant bone loss.
Case 2
A 52-year-old white female with a history of dental trauma
affecting the maxillary right central and lateral incisors,
presented to the Graduate Periodontics Clinic at the Uni-
versity of Michigan, Ann Arbor, Michigan, in October
2009. Written and oral informed consent to be treated
was obtained from the patient prior to commencement
of treatment. Both incisors were removed, and ridge pres-
ervation using allogenic bone graft was performed. Seven
months later, two dental implants were placed, but the im-
plant replacing the central incisor was placed too buccally

190 Clinical Advances in Periodontics, Vol. 4, No. 3, August 2014 Implant Position and Long-Term Success

FIGURE 6 Case 2. Presentation of implant failure because of incorrect bucco-palatal implant position. 6a Occlusal view of implant replacing the maxillary right
central incisor that was placed too buccally. 6b Buccal view of implant showing complete exposure of buccal surface. 6c Occlusal view of implant that was
placed too buccally.
(Fig. 6a). At implant uncovering, the implant replacing the
central incisor was not osseointegrated and was removed
(Figs. 6b and 6c). Therefore, this case presentation illus-
trates the complications associated with incorrect 3D im-
plant position in the maxillary anterior region.
Discussion
The bone- and soft-tissue loss in both horizontal and ver-
tical dimensions is an unavoidable consequence of tooth
removal. This phenomenon can be attributed to the bone
remodeling process, in particular the resorption of the bun-
dle bone on the buccal surface.13 A recent systematic review
on undisturbed healing of extraction sites in humans re-
ported 29% to 63% horizontal bone loss and 11% to
22% vertical bone loss 6 months after tooth extraction,
which occurred rapidly within the first 3 to 6 months.14
There was an associated 0.4- to 0.5-mm gain in soft-tissue
thickness at the 6-month follow-up.14 An animal model
demonstrated resorption of the buccal socket wall after
tooth extraction, which was even more significant at sites
with immediate implant placement.15 A retrospective study
demonstrated that a minimum buccal bone thickness of 2
mm was needed to avoid peri-implant mucosal recession
and bone loss.16 Having 2 mm of buccal bone thickness
would compensate for bone remodeling around the im-
plant platform, thereby maintaining a stable buccal bone
support for the overlying soft tissues.17 A recent multivar-
iate analysis demonstrated that midfacial mucosal reces-
sion around a dental implant was strongly associated
with a buccally placed implant.18 It was also found that
placing implants more lingually in freshly extracted sockets
not only minimized the exposure of the buccal implant
surface,19 but it also resulted in more bone formation on
the buccal surface.20 Therefore, to safeguard buccal bone
and soft-tissue levels, it is recommended to direct the im-
plant fixture toward the cingulum, leaving 2 mm of buccal
bone thickness. In the anterior region, having the implant
fixture placed palatally would allow for both a screw- or
cement-retained overlying restoration.
Studies on interradicular distance showed that a mini-
mum distance of 0.5 to 0.8 mm was needed to ensure
the existence of healthy and functional attachment ap-
paratus between teeth.21,22 A clear association of increased
bone loss between teeth was observed when the interradicular
Su, Fu, Wang
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P R A C T I C A L A P P L I C A T I O N S
distance was £0.8 mm.22 This could be attributable to
the inability to maintain good oral hygiene in these
areas, leading to rapid breakdown of a site with reduced
interradicular bone volume. If this safety zone was in-
fringed upon, circumferential peri-implant bone loss would
occur, leading to exposure of roughened implant sur-
faces, which are hard to maintain. The accumulation of
bacterial plaque makes the site susceptible to peri-implant
marginal bone loss.23 Therefore, extrapolating this sce-
nario to dental implants, adequate distance of 1.5 mm
between implant and root or 3 mm between implants main-
tains the peri-implant bone and thus preserves the papillary
tissues.
From an animal model, it was shown that implants
placed immediately in freshly extracted sockets should
be z1 mm apical to the buccal bone crest so as to avoid
the exposure of the rough implant surface.24 In another sce-
nario, it was observed that placement of consecutive im-
plants at different apico-coronal levels attributable to an
uneven bony plane resulted in bone remodeling to the most
apical level.9 This inevitably led to the exposure of implant
threads and their rough implant surfaces, thus bringing
about a domino effect whereby loss of peri-implant bone
consequently led to exposure of rough implant surface,
resulting in significant bacterial plaque accumulation
and additional bone loss.23 Therefore, it is suggested that
osteoplasty be performed with a tungsten carbide bur to
create a level bone surface. Bone-level implants are com-
monly placed 1 mm subcrestally and have a built-in plat-
form switch feature that together demonstrated minimal
peri-implant marginal bone loss.25 This is exceptionally
beneficial in the esthetic zone because it minimizes the risk
of esthetic complications.
The soft-tissue profile is essential in creating an esthetic
implant restoration. Several factors (e.g., position of im-
plant platform and thickness of soft tissue and buccal
bone) were reported as significant risk factors in causing
peri-implant midfacial mucosal recession.26 For exam-
ple, a buccally positioned implant platform would in-
crease the risk of midfacial recession by three times,27
and a thin-tissue biotype would result in greater peri-
implant mucosal recession.28 It was reported that sites
with thicker peri-implant tissue had lesser resorption
of the buccal bone.29 In addition, presence of sufficient
Clinical Advances in Periodontics, Vol. 4, No. 3, August 2014 191

P R A C T I C A L A P P L I C A T I O N S
keratinized mucosa was thought to be beneficial in the
prevention of peri-implant mucosal recession.30 There-
fore, soft-tissue grafting to increase tissue thickness of
peri-implant mucosa is beneficial in preventing peri-
implant mucosal recession.31 It was thus recommended
that soft-tissue grafting be performed at sites with a thin
buccal plate (<2 mm) or when the implant platform was
placed at the incisal position.32
Conclusions
Placement of dental implants in an ideal 3D position aids in
maintaining hard- and soft-tissue levels over time. Associa-
tive relationships are drawn between the effect of implant
positions and their long-term stability. Therefore, careful
192 Clinical Advances in Periodontics, Vol. 4, No. 3, August 2014
21630097, 2014, 3, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1902/cap.2013.120100 by Office Of Academic Resources Chulalongkorn University, Wiley Online Library on [31/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
retrospective analysis of implant position and peri-implant
tissue is needed to establish the relationship between im-
plant position, suprastructures, and peri-implant tissues. n
Acknowledgments
Figures 2, 3, and 4 are provided courtesy of Mr. Wee-Wah
Tok, Lead Systems Analyst, Department of Informatics and
Technology, Faculty of Dentistry, National University of
Singapore. The authors report no conflicts of interest re-
lated to this study.
CORRESPONDENCE:
Dr. Hom-Lay Wang, Department of Periodontics and Oral Medicine,
School of Dentistry, University of Michigan, 1011 N. University Ave., Ann
Arbor, MI 48109-1078. E-mail: homlay@umich.edu.
Implant Position and Long-Term Success

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